Advanced Transfusion Medicine: Adverse Reactions, Fatalities, and Clinical Protocols
Pre-Transfusion Testing and ABO Compatibility
Before a transfusion begins, blood must undergo an ABO check and the recipient must have their ABO and Rh blood grouping determined.
If the recipient possesses any antibodies, a direct cross-matching procedure is performed between the patient's serum and the donor red cells.
In cases where no antibodies are present, the blood component may be electronically matched.
ABO Antigens and Antibodies:
Individuals with blood group O possess anti-A and anti-B antibodies. Transfusing them with blood group A or B is incompatible.
Group O donors are considered universal red cell donors as their cells can be given to recipients of any blood group.
Individuals with blood group AB have cells that are unsuitable for donation to recipients of other groups, but they can receive blood from O, A, B, or AB donors.
Type A blood contains A antigens on the red cells and anti-B antibodies in the plasma.
Type O blood contains no antigens on the red cells but contains both anti-A and anti-B antibodies in the plasma.
Serological Testing for Blood Grouping
Blood typing is confirmed through serological aggregation tests using anti-A and anti-B reagents:
Type AB: Agglutinates/aggregates with both anti-A and anti-B.
Type B: No aggregation with anti-A; aggregates with anti-B.
Type A: Aggregates with anti-A; no aggregation with anti-B.
Type O: Does not agglutinate/aggregate with either anti-A or anti-B.
Clinical Goals and Procedural Hazards
The general goal of red cell transfusion is to raise the patient's hemoglobin by approximately .
Hazards exist at every stage of the detailed transfusion process:
Request Level: The primary risk mitigation is avoiding transfusion if the patient does not strictly need it.
Sample Collection: Correct patient identity is vital. Checking steps often include the patient confirming their own identity on the form.
Laboratory Processing: Critical points include sample receipt, testing, component selection, and component labeling.
Transportation: Blood is often picked up by a runner; it is vital to confirm it is the correct blood upon arrival at the ward or clinical setting.
Administration: Final confirmation involves checking the written request against the patient's identity at the bedside.
Special Blood Products and Indications
Irradiated Blood: Used for immunosuppressed patients (those with inherent immune deficiencies or undergoing T-cell suppressive treatments) to prevent the engraftment of lymphocytes from the donation, which causes graft-versus-host disease.
CMV Negative Blood: Specifically utilized for pregnant women and neonates.
Washed Red Cells: Provided for patients with a history of allergic reactions to remove residual plasma proteins.
HLA Matched Platelets: Utilized for patients demonstrating a poor response to standard platelet transfusions.
Rare Blood: May require the use of the patient's own autologous blood or blood directly from a relative.
Adverse Transfusion Reactions and Complications
Transfusion is essentially a graft and can cause infection, immunization, or other side effects.
Red Cell Complications: Hemolysis of transfused cells.
White Cell Complications: Formation of white cell antibodies leading to febrile reactions or poor responses to platelets.
Allergic Reactions: Reactions to donor proteins.
Storage Related Issues:
Red cells must not be stored too hot or too cold. Freezing can cause breakdown; excessive heat causes damage.
Platelets must be critically stored at room temperature.
Volume and Metabolic Complications:
Fluid Overload: Risk from the volume of red cells and fluids infused.
Hypothermia: May occur in massive transfusion settings; blood warmers are used to mitigate this.
Citrate Toxicity: Citrate in the blood product can "collapse" (chelate) calcium.
Acidosis or Potassium Infusion: High concentrations of can be infused with stored red cells.
Chronic Transfusion Risk: Iron stays in the recipient's body, requiring strategies to prevent iron overload.
Bacterial Contamination of Blood Components
Bacterial contamination is a dreaded infectious complication.
Clinical Signs: Immediate pain at the infusion site, fever or hypothermia, shaking chills (rigors), rapid pulse, low blood pressure (hypotension), immediate shock, or organ failure.
Visual Cues: Transfused units may look abnormal in the bag if infected.
Management Protocol:
Stop the transfusion immediately.
Investigate for blood group incompatibility and perform cultures.
Culture and Gram stain the unit being transfused.
Measure hemodynamic status and initiate broad-spectrum antibiotics for both Gram-positive and Gram-negative coverage.
Prevention Strategies:
Donors are deferred if unwell.
Strict cleaning of the phlebotomy site and environmental cleaning of centers.
Diversion Pouch: The first part of the blood collection is diverted into a pouch so any skin bacteria enter the sample, not the donation.
Bacterial Detection: Mandated cultures of platelets since April 2009.
Transfusion-Related Acute Lung Injury (TRALI)
Cause: Often results from infused antibodies (from the donor) or multiple biological "hits" during transfusion. Female donors may form white cell antibodies during pregnancy.
Pathophysiology: Antibodies bind to the recipient's white cells, resulting in pulmonary inflammation.
Prevention: Use of male-predominant Fresh Frozen Plasma (FFP). Female plasma is utilized for the production of IVIG and other products rather than clinical plasma transfusion.
Consensus Definition (2004):
New episode of lung injury occurring within of transfusion.
Absence of other causes.
Most common with plasma or granulocyte transfusions.
Absence of fluid overload: Normal central venous pressure (CVP) helps rule out overload.
Symptoms: Severe pulmonary edema, hypoxia, tachycardia, fever, cyanosis, and blood pressure fluctuations.
Treatment: Improvement is seen with respiratory support, but notably not with diuresis.
Fatal Transfusion Reactions and Case Studies
ABO Incompatibility is a major cause of fatalities; severity increases with the volume of incompatible blood transfused.
SHOT Case Series (UK) Example 1:
Two patients on the same ward had the same surname. One was group O (no transfusion needed), the other was group A (needed blood).
Blood meant for the group A patient was inadequately checked and given to the group O patient.
The group O patient had anti-A antibodies ( type) which caused the immediate breakdown of red cells, renal failure, coagulation triggering, and shock. The patient died within .
Case Study Example 2:
Checking was performed away from the bedside in a treatment room.
An interruption occurred, and a different unit was delivered and administered.
By chance, both the intended and actual recipient shared the same ABO group, so no clinical harm occurred despite the error.
Bedside Protocols and Identification Standards
Bedside Checking: Transfusions must be checked at the patient's bedside, never in a separate treatment room.
Night Transfusions: New South Wales specific instructions state to avoid transfusions at night to ensure adequate checking opportunities. Only urgent transfusions should occur after hours.
Patient/Relative Involvement: Patients or relatives sometimes report concerns that the blood is incorrect; these reports must never be overridden.
Identification Management:
Names: Use extra caution with shared surnames.
Casualty Situations: High-risk environments. Unknown labels should use non-sequential numbers to minimize confusion, often with estimated ages or other descriptors.
Fluid Status: Review fluid status and hand over progress during staff changes.
Checklists: Modeled after the airline industry to document consent, risk factors (older age, renal dysfunction, cardiac failure, use of diuretics), identity, and unit details.
Reporting: Adverse reactions, including suspected TRALI or contamination, must be reported to the blood service (Lifeblood) as per New South Wales health policy.
The website transfusion.com.au (Lifeblood) is a primary resource for transfusion information and career-long study.